Development and validation of a novel vancomycin dosing. Evaluation of a vancomycin dosing nomogram in achieving high. The authors developed a dosing nomogram that used ckdepicreatininecystatinc based estimated gfr egfrcrcysc as well as the target vancomycin trough level and patient weight. Analyze current guideline recommendations for vancomycin dosing and. Vancomycin regional guideline september 27, 2011 2 objectives to provide recommendations for. Therapeutic monitoring of vancomycin in adults summary of consensus recommendations from the american society of healthsystem pharmacists, the infectious diseases society of america, and the society of infectious diseases pharmacists. Evaluation of a pharmacistdirected vancomycin dosing and. This document refers to the treatment of adult patients unless otherwise stated. Guidelines for monitoring of vancomycin serum concentrations in adult patients. Vancomycin prescribing and therapeutic drug monitoring clinical guideline v6. Vancomycin pharmacokinetics vary widely between patients. Conversion from vancomycin trough concentrationguided dosing. The response to vancomycin was excellent, and the presence of this disease, also called acute staphylococcal ileocolitis, became an indication for the use of vancomycin.
Clinical pharmacokinetics of vancomycin springerlink. The use of a vancomycin dosing nomogram is an alternative and more costeffective method to conventional dosing. Department of pharmacotherapy and pharmacy services, university. Prospectively validated dosing nomograms for maximizing the. Validation of the effectiveness of a vancomycin nomogram in achieving target trough concentrations of 1520 mgl suggested by the vancomycin consensus guidelines. Vancomycin is a glycopeptide antibiotic used to treat severe grampositive.
Vancomycin is a glycopeptide antibiotic used to treat severe grampositive infections due to organisms that are resistant to other antibiotics such as. Recent studies have focused on characterising the disposition of vancomycin in patients and assessing the relationship between serum concentrations and therapeutic as well as adverse effects. It exerts its bactericidal effect by complexing with the dalanyldalanine portion of the peptide. December 2011 faqs drug information group university of. Therapeutic monitoring of vancomycin in critical ill patients.
Two recent studies employed a practical approach to development and implementation of a cystatin cinclusive vancomycin dosing nomogram in clinical practice. Laboratory tests to direct antimicrobial pharmacotherapy. Target vancomycin serum levels for specific indications and pathogens. This integrated nomogram is a tool that clinicians can use in selecting appropriate initial vancomycin regimens on the basis of age and serum creatinine, to achieve hightarget levels of 1520 mgl. An overweight male, 43 years of age, 62 in height and 300 lbs in weight acquired s. Detroit receiving hospital and university health center. Denetclaw et al11 evaluated divided vancomycin lds in 69 adult icu patients in a prospective, observational study. Jan 01, 2006 vancomycin is a large glycopeptide compound with a molecular weight of. Regular spot plasma vancomycin concentrations should be monitored, generally starting within 24 hours of the first dose, and measured daily. Guidelines for monitoring of vancomycin serum concentrations. Evaluation of the effectiveness of a vancomycin nomogram at predicting trough levels within a therapeutic range 714 mgl to avoid development of resistance, and ideally between 15 mgl and 20 mgl for complicated infections such as osteomyelitis, endocarditis, meningitis, bacteremia, and hospitalacquired. Vancomycin therapeutic drug monitoring vancouver coastal. A high dose vancomycin nomogram hdvn was developed to recommend a dose and frequency to target troughs of 15 to 20 mgl.
Achievement of optimal vancomycin exposure is crucial to improve the management of patients with lifethreatening infections caused by susceptible grampositive bacteria and is of particular concern in patients with augmented renal clearance arc. Performance of a dividedload intravenous vancomycin. Impact of vancomycin therapeutic drug monitoring on patient. Concerning this recommendation, several nomograms have been constructed targeting this optimal trough level range in different populations of patients.
Prospective trial of a novel nomogram to achieve updated. Iv vancomycin dosing and monitoring antibiotic guidelines. Vancomycin nomogram goal trough 1520 mcgml 45 120 70 65 60 75 100 95 80 85 90 110 115 105 1500 q12 3417 1500 q12 3519 q8 2716 q8 2817 1500 q12. Patients in the tdm group had vancomycin drug therapy monitored daily by a pharmacist and vancomycin dosages adjusted following a pharmacokinetic analysis of vancomycin serum concentrations. Vancomycin levels should be repeated until there are two consecutive levels within target range. Pharmacistled implementation of a vancomycin guideline across medical and surgical units. Higher doses 250 or 500 mg qid are sometimes recommended for patients with very severe cdi, without supporting clinical evidence.
Published interpatient variability has been reported as 0. This study aimed to develop two vancomycin nomograms for the achievement of. Conversion from vancomycin trough concentrationguided dosing to. Vancomycin utilisation has increased dramatically in the last 10 years due to the increasing clinical significance of infections with methicillinresistant staphylococci. The results of this study revealed that implementation of a vancomycin nomogram into a cpoe system was associated with an increased percentage of patients with an. Full text pharmacistled implementation of a vancomycin. Based on our results, we found that implementation of a vancomycin nomogram in critically ill patients using actual body weight and the mdrd equation as an estimate of glomerular filtration rate to determine dosing frequency was more successful in achieving an initial vancomycin trough concentration 15. Faecal pharmacokinetics of orally administered vancomycin in. Denetclaw et al11 evaluated divided vancomycin lds in 69 adult icu patients in a prospective, observational study table 1. The journal of human pharmacology and drug therapy. Guidelines developed by uwhc department of pharmacy. Evaluation of the effectiveness of a vancomycin nomogram at.
Vancomycin nomogram guidelines in a cpoe system medscape. For patients in the nontdm group, the pharmacist only completed a data collection form. A novel vancomycin dosing nomogram was developed and validated at 2 canadian teaching hospitals. Evaluation of a vancomycin dosing nomogram in obese. Although numerous publications in the past several years have described the pharmacokinetics of vancomycin in various patient populations, disparity still exists regarding the most appropriate methods of monitoring, including therapeutic range, timing of peak determinations, and methods for determining doses. Vancomycin is bactericidal and exhibits timedependent or concentrationindependent bacterial killing. Monographs for commonly administered intravenous medications. The vancomycin dose was based on 15 mg of vancomycin per kilogram of total body weight. Adult patients 18 years or older who were started on vancomycin using the hdvn and had at least one vancomycin trough drawn at steady state between july 2011 and june 2012 were included. The results of this study revealed that implementation of a vancomycin nomogram into a cpoe system was associated with an increased percentage of patients with an initial optimal vancomycin. To determine if the use of a novel vancomycin nomogram predicts dosing regimens that achieve target trough concentrations equal to or more accurate than dosing regimens calculated using. Aim for a target of 20 mgl a target of 25 mgl may be used for cns infections. Cystatin c is a renal biomarker that has been proposed to be used as an alternative to or in conjunction with creatinine for estimating glomerular filtration rate gfr.
Concerning this recommendation, several nomograms have been constructed targeting this optimal trough level range in different populations of. Vancomycin is one of only a few antibiotics available to treat patients infected. Feb 17, 2009 after more than five decades of widespread clinical use, vancomycin may still have a major role in the treatment of multidrugresistant grampositive bacterial infections 18, 23, even though its clinical efficacy for the treatment of deepseated infections is often called into question because of it poor penetration into tissue and its relatively weak antibacterial activity 5, 33. And significantly more patients had a vancomycin trough concentration within the target range when vancomycin was dosed by the nomogram for these patients as well. Evaluation of the effectiveness of a vancomycin nomogram. After this, vancomycin levels can be repeated every 3 days or whenever there is a significant change in bodyweight, serum creatinine or if the dose has been adjusted. It is active against staphylococci including penicillin and oxacillinresistant strains, streptococci, enterococci, and other grampositive organisms. Vancomycin regional guideline september 27, 2011 8 appendix 1 dosing recommendations for obese patients the formal definition of obesity is defined as a bmi of 30 or more. The dosing interval of the nomogram was based on that published by matzke et al. Vancomycin casebook in clinical pharmacokinetics and. For obese patients total body weight 20% over ideal body weight, dosage requirement may best be estimated using an. Vancomycin nomogram goal trough 1520 mcgml 45 120 70 65 60 75 100 95 80 85 90 110 115 105 1500 q12 3417 1500 q12 3519 q8 2716 q8 2817 1500 q12 1250 q8 3118 1250 q8 3219 20 55 50 30 25 40 35 3316 75 l 1500 q8 3217 1500 q8 3318 1250 q8 2916 1250 q8 3016 70 l 1500 q8 3418 1250 q8 3016 3317 q24 2917 1500 q36 1250. Two recent studies employed a practical approach to development and implementation of a cystatin cinclusive vancomycin dosing nomogram in clinical. Annals of pharmacotherapy vancomycin loading doses.
To determine if the use of a novel vancomycin nomogram predicts dosing regimens that achieve target trough concentrations equal to or more accurate than dosing regimens calculated using traditional pharmacokinetic calculations, evaluate the incidence of subtherapeutic and supratherapeutic troughs, and assess pharmacists impressions of the nomogram. Validation of the effectiveness of a vancomycin nomogram. Vancomycin hydrochloride has the following structural formula. Page 1 of 3 detroit receiving hospital and university health center vancomycin dosing nomogram table. Oral vancomycin 125 mg qid is recommended as treatment of severe clostridium difficile infection cdi. Pharmacistmanaged intravenous iv vancomycin protocol. Vancomycin loading doses in ed not associated with increased nephrotoxicity. Vancomycin is used for the treatment and prevention of various bacterial. Vancomycin prescribing and therapeutic drug monitoring. Evaluation of a high dose vancomycin nomogram and the n. This is the first time that a vancomycin nomogram has been constructed to achieve a trough concentration at the higher target range of 1520 mgl in an asian population.
Vancomycin injection, usp in the galaxy plastic container pl 2040 is a frozen, iso osmotic, sterile, nonpyrogenic premixed 100 ml, 150 ml, or 200 ml solution containing 500 mg, 750 mg, or 1 g vancomycin respectively as vancomycin hydrochloride. Vancomycin is a tricyclic glycopeptide that has gained clinical importance thanks to its effectiveness against organisms such as mrsa and enterococci. Vancomycin routine monitoring should be a single trough level at steady state. Treatment of mssa or other susceptible gram positive. Recent guidelines recommend a vancomycin trough predose level between 15 and 20 mgl in the treatment of invasive grampositive infections, but most initial. Vancomycin dosing nomograms targeting high serum trough. Pharmacokinetic and pharmacodynamic properties of vancomycin. It is not appreciably absorbed orally and is eliminated primarily via the renal route, with 80%90% recovered unchanged in urine within 24 h after administration of a single dose. Generally, the combination of a betalactam antibiotic or vancomycin with either gentamicin or streptomycin is considered to be synergistic in killing the bacterial organism. Evaluation of a pharmacistdirected vancomycin dosing and monitoring pilot program at a tertiary academic medical center article pdf available in annals of pharmacotherapy 499 may 2015 with. Decreasing the time to achieve therapeutic vancomycin. Evaluation of the effectiveness of a vancomycin nomogram at predicting trough levels within a therapeutic range 714 mgl to avoid development of resistance, and ideally between 15 mgl and 20 mgl for complicated infections such as osteomyelitis. Monographs for commonly administered intravenous medications in home and community care 2 p a g e vancomycin administration1,2 a central line is preferred for administration of vancomycin, especially if concentration of mixed solution is 510 mgml usually in fluid restricted patients or if being administered for more than one week.
Compared with aminoglycosides, the variability in the distribution volume of vancomycin is extreme. Vancomycin is a glycopeptide antibiotic, approved by the fda in 1958, which is slowly bactericidal against most grampositive organisms. Notable studies analyzing vancomycin dosing in obese patients have utilized protocols or nomograms that have based dosing on simplified mgkg calculations paired with estimated renal function for determining frequency. It has activity against grampositive rods and cocci, gramnegative rods are resistant to its bactericidal action. Interval depends on patients renal function and targeted serum vancomycin concentration refer to tables on following page clinical pearls. Use of ideal body weight ibw for determining the mgkgdose appears to be more accurate than dosing on the basis of total body weight tbw. Evaluation of a vancomycin dosing nomogram based on the. To assess and validate the effectiveness of a newly constructed vancomycin dosing nomogram in achieving target trough serum concentrations of 1520 mgl. Use of ideal body weight ibw for determining the mgkgdose appears to be more accurate than dosing on the basis of total body. This integrated nomogram is a tool that clinicians can use in selecting appropriate initial vancomycin regimens on the basis of age and serum creatinine, to. The patient should be at steady just before the fifth dose. Pdf prospective trial of a novel nomogram to achieve.
After more than five decades of widespread clinical use, vancomycin may still have a major role in the treatment of multidrugresistant grampositive bacterial infections 18, 23, even though its clinical efficacy for the treatment of deepseated infections is often called into question because of it poor penetration into tissue and its relatively weak antibacterial activity 5, 33. Prospectively validated dosing nomograms for maximizing. The patients and physicians were unaware of the monitoring. Mediakit reprints and eprints sponsored supplements branded books. This book is distributed under the terms of the creative commons. Sep 12, 2016 therapeutic monitoring of vancomycin in adults summary of consensus recommendations from the american society of healthsystem pharmacists, the infectious diseases society of america, and the society of infectious diseases pharmacists.
490 1326 699 1283 413 303 704 309 1484 79 201 677 623 794 993 946 578 238 1268 585 659 362 675 543 232 105 525 271 1329 386 236 80 151 58 816 1131 692 670 672 263 194 385 1013 780 385